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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604607
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:55:26 PM

Document Has Been Signed on 03/13/2024 12:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SUNSET RESIDENTIAL CARE IFACILITY NUMBER:
374604607
ADMINISTRATOR:LOPEZ, YANET PUENTESFACILITY TYPE:
740
ADDRESS:2707 NANSEN AVETELEPHONE:
(858) 352-6340
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY: 6CENSUS: 5DATE:
03/13/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Administrator Yanet PuentesTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Annual Continuation Inspection. The LPA introduced himself and disclosed the purpose of the visit to Administrator Yanet Puentes. The facility was licensed for capacity of six (6) non-ambulatory residents, and approved for a hospice waiver for six (6) residents.

During the annual visits the facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.
Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients.
Medications were labeled, and stored in locked areas. No pools, nor bodies of water were observed on the premises. Per staff, no firearms, nor ammunition were kept at the facility. A carbon monoxide detector, facility telephone, and fire extinguisher were present. Required licensing postings were observed in visible areas of
the facility.

The LPA interviewed staff and reviewed multiple staff and client records/files. Technical advised was provided and deficiencies noting missing documents were cited in an LIC 809D. A plan of correction was jointly formulated with the administrator.

An exit interview was conducted with Administrator Puentes, to whom a copy of this report, LIC 809D, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2024 12:55 PM - It Cannot Be Edited


Created By: Sabel Martinez On 03/13/2024 at 11:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSET RESIDENTIAL CARE I
FACILITY NUMBER: 374604607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on an interview and review of records, the licensee did not comply with the section cited above, which posed a potential health, safety or personal rights risk to persons 5 of 5 residents in care.
POC Due Date: 04/12/2024
Plan of Correction
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Administrator agreed to conduct and document an emergency drill, by 04/12/2024. The administrator will submit documentation to the LPA, by 4/12/24.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and review of records, the licensee did not comply with the section cited above in 3 of 5 residents (R1,R2, and R3), which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Administrator agreed to obtain a completed hospice care plan and submit it to the LPA, by 4/12/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024


LIC809 (FAS) - (06/04)
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